Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wellbridge Of Pinckney during CMS and state inspections, most recent first.
A resident with multiple comorbidities and a history of falls was found on the floor with significant injuries after their bed was discovered at an unusually high position, despite staff reporting it had been left in the lowest position. The facility did not conduct a thorough root-cause analysis, failed to review available camera footage, and lacked documentation supporting claims that the resident could have raised the bed, resulting in a deficiency related to accident prevention and investigation.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
The facility failed to provide adequate supervision and accurate documentation for several residents, resulting in incidents of elopement and falls. A resident with dementia was found outside the facility, and their wandering assessment was incomplete. Another resident with a history of falls was inaccurately assessed, leading to repeated falls without proper care plan updates. Additionally, a resident's fall resulting in a wrist fracture was not accurately documented, and a neurological assessment was found to be false.
The facility failed to ensure timely physician visits for residents, with several cases where initial comprehensive visits were conducted by an NP instead of a physician, and required visit frequencies were not met. Residents expressed concerns about not being seen by their doctor, and records showed significant gaps between visits. Staff interviews revealed a lack of adherence to the required schedule for physician visits.
A resident with congestive heart failure experienced a significant medication error when their prescribed Lasix was not administered until two days after admission. The facility also failed to consistently monitor the resident's weight as ordered by the physician, leading to unrecognized weight gain. The resident's wife raised concerns about the care provided, highlighting the lack of adherence to the physician's plan of care and the absence of communication with the cardiologist.
A facility failed to ensure proper documentation and assessment for a resident's seatbelt use in a wheelchair. The resident, with severe cognitive impairment, could not independently release the seatbelt without assistance. The facility lacked a physician's order, consent, and current assessment for the seatbelt, which was inaccurately listed under 'falls' for safety. The DON claimed the seatbelt was not a restraint, but it was not reassessed quarterly as required, leading to a deficiency.
A resident with dementia was found outside the facility by a CNA, who failed to report the incident as per protocol. The DON and Administrator were informed but did not report the incident to the State Agency until several days later. The facility's investigation was delayed and incomplete, with inconsistencies in documentation and failure to follow the elopement policy, leading to a deficiency citation.
A resident with dementia was found outside the facility, but the incident was not documented in their medical record, and the facility failed to follow its policy to investigate and report the elopement. The DON and Administrator were informed, but a thorough investigation was delayed, and the facility's investigation file lacked essential details. The facility's camera footage was unavailable for review.
A resident was found with a cup of pills left on their breakfast tray, which they were unable to identify. Nurse E, responsible for the resident, incorrectly documented that the medications were administered, despite not witnessing their consumption. The DON confirmed that Nurse E should not have left the medications unattended and should not have recorded them as administered without verification.
A resident with an indwelling foley catheter was found without a securement device, which was observed on the bathroom floor. The resident, who required assistance due to a fall, was unaware of the device's removal. The LPN confirmed the absence of a securement device and obtained a new one. The facility's documentation showed gaps in catheter care records, and the care plan was updated only after the surveyor's observation. Interviews with staff revealed a lack of clarity on the situation, and the facility's procedure for securing catheters was not followed.
A facility failed to readmit a resident after hospital clearance and did not provide necessary discharge documentation. The resident, with a history of traumatic brain injury and other medical conditions, required maximum assistance for ADLs. The facility cited issues with the resident's Guardian as the reason for non-readmission, despite confirming they could meet the resident's needs. The NHA admitted to not providing the required discharge paperwork.
Failure to Prevent Avoidable Fall and Incomplete Root-Cause Analysis
Penalty
Summary
A deficiency occurred when the facility failed to prevent an avoidable fall and did not conduct a thorough root-cause analysis for a resident who sustained significant injuries, including fractures of the clavicle and thoracic vertebra. The resident had a history of repeated falls, stroke, heart disease, vascular dementia with behaviors, and adjustment disorder, and was on hospice care. On the day of the incident, the resident was found on the floor next to their bed with visible injuries. Both the nurse and CNA who responded to the incident observed that the bed was at an unusually high position, approximately waist level, despite both reporting that it had previously been left in the lowest position after care was provided. The facility's investigation into the incident was limited and did not identify a root cause for the fall. Statements from staff were collected, including a housekeeper who denied raising the bed and claimed to have entered the room only after the incident. The investigation did not include a review of available hallway camera footage to verify the timeline or determine if anyone else entered the room and raised the bed. Additionally, there was no documentation in the resident's care plan or clinical record indicating that the resident had a history of manipulating bed controls or exhibiting restless behaviors that could explain the bed being raised. Despite suggestions from facility leadership that the resident may have raised the bed themselves due to restlessness, there was no supporting evidence in the clinical record or staff interviews to substantiate this claim. The facility's investigation file lacked a documented root cause analysis, and the interdisciplinary team did not provide an analysis as required by the facility's own Falls Reduction Program policy. The failure to ensure the bed was kept in the lowest position and to conduct a comprehensive investigation into the circumstances of the fall contributed to the deficiency.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Inadequate Supervision and Documentation Lead to Resident Incidents
Penalty
Summary
The facility failed to ensure the safety and adequate supervision of several residents, leading to incidents of elopement and falls. One resident, diagnosed with dementia, was found outside the facility by a CNA, indicating a lapse in supervision and documentation. The resident's medical record did not reflect the elopement incident, and the wandering assessment was inaccurately completed, failing to document the resident's behavior and history of wandering. Another resident with a history of falls and requiring assistance for daily activities was inaccurately assessed as a moderate fall risk upon admission. The care plan did not adequately address the resident's unsteady gait and history of falls, and there was a lack of documentation and intervention following a fall on January 21st. The facility's failure to update the care plan and accurately assess the resident's fall risk contributed to repeated falls. A third resident experienced a fall resulting in a wrist fracture, yet the facility's records did not accurately reflect the incident or the resident's fall risk. The fall risk assessment was inconsistent with the resident's condition and medication use, and there was a delay in conducting a physical therapy evaluation. Additionally, another resident's fall was not properly documented, and the neurological assessment provided was deemed false, as it included data recorded while the resident was in the emergency room.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that residents received the required physician visits as mandated by regulations. Specifically, the facility did not consistently ensure that physician visits occurred at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. This deficiency was observed in six residents, where either the initial comprehensive visit was not conducted by a physician or the frequency of visits did not meet the required schedule. For instance, one resident was admitted with multiple diagnoses, including dementia and chronic kidney disease, but did not receive timely visits from the assigned physician. In several cases, the initial comprehensive visit was conducted by a Nurse Practitioner (NP) instead of the assigned physician, which is against the required protocol. For example, one resident with acute and chronic respiratory failure had their first visit conducted by an NP rather than the physician. Another resident with congestive heart failure also had their initial visit conducted by an NP, with the physician only consulting two days later. These actions indicate a failure to adhere to the required protocol for initial comprehensive visits by a physician. Additionally, there were instances where residents expressed concerns about not being seen by their physician, and the facility's documentation did not reflect timely physician visits. One resident, who had been at the facility for about two years, reported not being seen by their doctor despite requesting a visit. The facility's records showed significant gaps between physician visits, with some residents not being seen for several months. Interviews with staff, including the Director of Nursing and a Nurse Practitioner, revealed a lack of adherence to the required schedule for physician visits, further contributing to the deficiency.
Failure to Administer Lasix and Monitor Weight in Resident with CHF
Penalty
Summary
The facility failed to prevent a significant medication error for a resident with a primary diagnosis of acute on chronic systolic congestive heart failure. Upon admission, the resident was prescribed Lasix, a diuretic medication, to manage their condition. However, the medication was not administered until two days after admission, despite the last dose being given three days prior. There was no documentation explaining the omission of the Lasix doses, nor was there any record of the physician being notified for further directives. Additionally, the facility did not adhere to the physician's orders for daily weight monitoring, which is crucial for managing congestive heart failure. The resident's weight was not recorded on several days, and there was a discrepancy between the physician's plan of care and the facility's implementation of weekly weight orders. This lack of consistent weight monitoring led to a failure in identifying the resident's weight gain, which was a critical indicator of their health status. The resident's wife expressed concerns about the care provided, particularly regarding the administration of Lasix and the monitoring of the resident's condition. Despite the physician's notes indicating the need for daily weights and adjustments in Lasix dosage, these were not consistently followed, and there was no notification to the cardiologist as instructed by the transferring hospital. The facility's oversight in medication administration and weight monitoring contributed to the significant medication error and inadequate management of the resident's congestive heart failure.
Failure to Properly Assess and Document Seatbelt Use
Penalty
Summary
The facility failed to ensure proper documentation and assessment for the use of a seatbelt device on a resident, identified as R7, who was observed in a wheelchair with the seatbelt clasped. R7, who has severe cognitive impairment and a history of falls, was unable to independently release the seatbelt without cues and assistance. The facility did not have a physician's order, consent, or a current assessment for the seatbelt device, which was last assessed in 2021. The care plan inaccurately listed the seatbelt under 'falls' for safety, despite no indicators for restraint use being noted in the resident's assessments. The Director of Nursing (DON) claimed the facility was restraint-free and stated that the seatbelt was not considered a restraint because R7 could remove it with assistance. However, the seatbelt was not reassessed quarterly as required, and there was a discrepancy between the care plan and the family's understanding of the seatbelt's purpose. The family believed the seatbelt was for comfort due to R7's past work experience, while the facility's documentation suggested it was for trunk support and positioning. The lack of proper assessment and documentation led to the deficiency noted by the surveyors.
Failure to Timely Report Elopement Incident
Penalty
Summary
The facility failed to timely report an elopement incident involving a resident, identified as R89, to the State Agency (SA). R89, who has dementia and is unable to make medical decisions, was found outside the facility by a CNA, identified as CNA H, on their last working day. The CNA brought the resident back inside but did not report the incident according to the facility's protocol. The Director of Nursing (DON) and the Administrator were informed of the incident on 3/30/25, but the incident was not reported to the SA until 4/3/25. The facility's investigation into the incident was delayed and incomplete. The Administrator and Nurse Consultant A were unable to provide a complete investigation report or an Incident and Accident report when requested by surveyors. The facility's documentation was inconsistent, with a corrective action for CNA H being backdated and not accurately reflecting the follow-up actions taken. The Administrator admitted to errors in the report submitted to the SA, which inaccurately described the surveyors' findings. The facility's policy on elopements, which requires prompt reporting and documentation of such incidents, was not followed. The lack of timely reporting and accurate documentation of the elopement incident led to a deficiency being cited during the survey. The facility's failure to adhere to its own policies and procedures contributed to the deficiency identified by the surveyors.
Failure to Investigate Resident Elopement
Penalty
Summary
The facility failed to thoroughly investigate an elopement incident involving a resident diagnosed with dementia, who was found outside the facility. The resident, who was unable to make medical treatment decisions and had an activated power of attorney, was discovered by a CNA outside the facility under the awning. Despite the incident occurring, there was no documentation in the resident's medical record about the elopement, and the facility did not follow its policy to investigate and report the incident. The Director of Nursing (DON) and the Administrator were informed of the incident, but there was a delay in initiating a thorough investigation. The CNA who found the resident outside reported the incident to other staff members, but there was no follow-up or documentation of the event in the resident's medical record. The facility's investigation file lacked a narrative of the incident, findings, root cause identification, and accountability or supervision issues related to the staff assigned to the resident. The facility's policy on elopements, which requires staff to investigate and report all cases of missing residents, was not followed. The Administrator and corporate staff failed to provide a complete investigation or an Incident and Accident report to the surveyors by the end of the survey. Additionally, the facility's camera footage, which could have provided more information about the incident, was not available for review as it was only kept for 24 hours.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medication according to professional standards of practice for a resident, identified as R12. On April 1st, R12 was observed with a full breakfast tray and a small cup containing approximately 10 pills. R12, who was alert but unable to explain the presence of the pills, had a recent BIMS score indicating intact cognition and a court-appointed guardian. Nurse E, responsible for R12, initially believed the resident had taken the medication and later asked R12 to take the pills without providing their names. The clinical record showed no order allowing R12 to self-administer medication. Nurse E documented in the Medication Administration Record (MAR) that the medications were administered at 8:36 AM, despite the pills being observed untouched and dry on the tray at 10:03 AM. The Director of Nursing (DON) confirmed that Nurse E should not have left the medications with the resident and should not have recorded them as administered without witnessing their consumption. The medications included Jardiance, Duloxetine, Metoprolol, Zyrtec, Atorvastatin, Glipizide, Ferrous Sulfate, and Depakote, which were critical for managing R12's conditions such as diabetes, depression, high blood pressure, and anemia.
Failure to Secure Foley Catheter Properly
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling foley catheter, leading to the potential for catheter dislodgement, urethral trauma, and urinary tract infection. The resident, who was admitted with diagnoses including urinary retention, neuromuscular dysfunction of the bladder, and dementia, was observed without a securement device for their catheter. The securement device was found on the bathroom floor, and the resident was unaware of how it was removed. The resident required assistance with transfers due to a fall and was being helped by staff. During the survey, the LPN assigned to the resident confirmed the absence of a securement device and was unsure how it came off. The LPN disposed of the device found on the floor and obtained a new one. The Director of Nursing was informed of the situation, and it was noted that the resident's care plan was updated only after the surveyor's observation. The facility's documentation showed gaps in the treatment administration record, with several blank entries for catheter care. Interviews with staff, including a CNA and the Unit Manager, revealed a lack of clarity on how the securement device ended up on the floor and an acknowledgment of the concern regarding the absence of a securement device. The Director of Nursing was questioned about the facility's standards for foley care and the lack of prior documentation of the resident's non-compliance with the securement device. The facility's procedure for indwelling catheter care requires proper securing of the tubing to the leg, which was not adhered to in this case.
Failure to Readmit Resident and Provide Discharge Documentation
Penalty
Summary
The facility failed to permit a resident, identified as R901, to return after being medically cleared from the hospital and did not provide the necessary facility-initiated discharge documentation. The resident had a history of traumatic brain injury, hypertension, asthma, dysphagia, and seizures, requiring maximum assistance for all Activities of Daily Living (ADL) and experiencing significant cognitive and communication loss. The issue arose when the facility's physician ordered the resident to be sent to the Emergency Department due to high blood pressure, but upon medical clearance, the facility did not readmit the resident. The Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility could meet all of R901's needs but chose not to accept the resident back due to a strained relationship with the resident's Guardian. The Guardian was reported to intimidate and threaten staff and interfere with the resident's care. Despite attempts to address grievances formally, the Guardian filed concerns directly with the State Agency. The NHA acknowledged informing the Guardian that the resident would not return and admitted that the required discharge documentation was not provided.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 145 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pinckney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency At Whitmore Lake | 9.6 mi | ★★★★★ | 3 | 0 |
| Wellbridge Of Brighton | 10 mi | ★★★★★ | 7 | 0 |
| Caretel Inns Of Brighton | 10.2 mi | ★★★★★ | 6 | 0 |
| Chelsea Retirement Community | 10.4 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Howell | 10.6 mi | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.